ForensicDentistry

Iain A Pretty

Forensic Dentistry: 2. Bitemarks

and Bite Injuries
Abstract: While the practice of human identification is well established, validated and proven to be accurate, the practice of bitemark
analysis is less well accepted. The principle of identifying an injury as a bitemark is complex and, depending on severity and anatomical
location, highly subjective. Following the identification of an injury as a bitemark, the comparison of the pattern produced to a suspects
dentition is even more contentious and an area of great debate within contemporary odontological practice. Advanced techniques using
digital overlays have been suggested, yet studies have shown that these can be inaccurate and there is no agreement as to the preferred
method of comparison. However, the advent of DNA and its recovery from bitemarks has offered an objective method of bitemark analysis.
Despite the strengths of DNA, the physical comparison of a suspects dentition to bitemark injuries is still commonplace. The issues within
bitemark analysis are discussed and illustrated with case examples.
Clinical Relevance: Dentists should be aware of where bitemarks are most commonly found, and of their significance in cases of children,
the elderly and spousal abuse.
Dent Update 2008; 35: 48-61

Introduction

these are discussed in this article.

Crime types

Bitemark injuries are found

in some of the most serious crimes and
may often be the only physical evidence
available, especially in the late presenting
living victim.1,2 Crimes featuring bitemarks
include abuse (child, spousal and elder),
rape, assault, homicide, and exceptional
cases such as bank robberies (where a
suspect has held, for example, a cheque book
between their teeth) can also be found in
the literature. Owing to the serious nature
of these crimes, investigators are keen to
explore all the physical evidence and it is only
correct that such injuries should be recorded,
documented and described in terms of
their size, location and severity. However, all
bitemarks must be carefully examined and
their forensic significance determined before
any comparative analyses are undertaken.3
The forensic significance of bitemarks is
dependent on a number of variables and

Iain A Pretty, BDS(Hons), MSc, PhD, MFDS

RCS(Ed), Senior Lecturer, Dental School
and Hospital, Manchester, UK.

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Anatomical location

It is important that dentists, police

officers, social workers, forensic pathologists
and others involved in the criminal justice
system be aware of where bitemarks are
most commonly found. It is also important
to remember that bitemarks can be both
attack injuries (and therefore present on the
victim) and defensive wounds (and therefore
present on the suspect) and all individuals
suspected of involvement in a crime against a
person need to be examined for such marks.4
A survey of 148 bitemarks was conducted
in order to determine the anatomical areas
most likely to be bitten; the results are
shown in Figure 1.1 Females were four times
more likely to be bitten than males, and
over 50% of the males in the study were the
suspects in the case reinforcing the need to
examine carefully this group of individuals for
bitemark evidence. Females were most likely
to be bitten on the breast, arm and legs, and
children on their genitals, legs and back. Most
males were bitten on the hand, back or face.1
The anatomical location of a
bitemark is also crucial in determining its
potential to be analysed. If one considers that

the breast is by far the most commonly bitten

location, this presents a considerable problem.
Breast tissue is highly mobile and easily
deformed and therefore it can be difficult to
determine the position of the breast during
biting or the effect of the bite force on the
deformity of the tissue and hence the injury.5,6
Bitemarks on the arm and leg can be similarly
affected, depending on their position at the
time of biting.5,6
Presentation of bitemark injuries

Bitemarks will typically present

as a semi-circular injury which comprises two
separate arcs (one from the upper teeth, the
other from the lower) with either a central
area absent of injury, or with a diffuse bruise
present.7 It is not unusual to see only one arch
of teeth on an injury and, if this is the case, it
is most often the lower teeth that are present
which relates to the mechanics of biting, ie
the maxilla remains stable while the mandible
moves until the teeth meet.7 There are three
main factors that influence the severity of a
bitemark injury:
The force by which the original injury was
inflicted;
The anatomical location bitten; and
The time elapsed between infliction
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should receive medical attention as such

wounds are highly susceptible to serious
infections.

Collection of bitemark evidence

Figure 1. Anatomical distribution of 148 bitemarks from the United States.

of the injury and the presentation to the

odontologist.
It is therefore possible to have a diffuse
bitemark comprised only of faint bruising
that may have been a severe bitemark but
has presented some weeks after infliction.8
The severity of a bitemark is an important
factor within the assessment of the forensic
significance of the injury and whether or not
it can be compared with a suspect. Figure 2
illustrates the scale of severity and significance
and Figure 3 presents illustrative examples of
the index.
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It can be seen from this scale that

the most forensically significant bitemarks are
those that fall in the middle of the severity
scale, ie those that are too slight and those
that are too severe rarely offer sufficient detail
to be of forensic value. It is important to note,
however, that a mild bitemark should not
be considered a trivial injury. Any bitemark
that is visible after more than a few minutes
is likely to have caused considerable pain
and therefore should be regarded as serious.
In addition, any living individual who has
received a bite that has broken the skin

Two aspects of forensic

significance have been discussed, the
anatomical location and the severity. A
third influence on the ability of the injury
to be properly assessed is the quality of the
evidence collection.9 It is not unusual for
forensic odontologists to be presented with
evidence that has been collected in their
absence, either because the case is being
reviewed by them, for example in the case
of a defence instruction, or as a result of
the inability of the odontologist to attend
the mortuary, hospital or custody centre.10
It should be emphasized that it is always
preferable that the odontologist attends if
at all practical the supervision of evidence
collection ensures that this is of the highest
standard.
Bitemark evidence is collected
from both the bite victim and suspect, but
it should be remembered that the bite
victim could be the suspect in the case. In
most instances the odontologist will collect
the evidence from the bite suspect, as this
involves techniques (such as impression
taking) that can only be undertaken by a
trained clinician. The American Board of
Forensic Odontology (ABFO) has published
guidelines that described the evidence that
should be collected from both victim and
suspect and they represent a sound basis
for such collection. Deviations from these
recommendations may be questioned
and therefore it is the responsibility of the
odontologist to inform, and possibly train,
those individuals within their jurisdiction
charged with the collection of such items of
evidence.11 The British Association of Forensic
Odontology (BAFO, www.bafo.org.uk) have
also developed broadly similar guidelines but
these have yet to be published in the peerreviewed literature.
Collection of bitemark evidence from the bite
victim

The most important item of

evidence from the bite victim is photography.
Numerous photographs of the injury should
be taken. Shots would include:
With and without the ABFO No. 2 scale;
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collection of evidence from bite victims is the

acquisition of 3D images of the bitemark. This
is performed using specialist software, such as
that produced by LuminIQ (LuminIQ, Seattle,
Washington) and enables, by assessment
of grey scale levels, a three-dimensional
rendition of standardized images. An example
of a bitemark processed in this way is shown
in Figure 6. Further work is required to
validate these techniques, but they may offer
a means of demonstrating the depth of an
injury without the problematic use of skin
impressions.
Collection of evidence from the bite suspect

Figure 2. The bitemark severity and significance scale.

In colour and black and white;

On and off camera flash (oblique flashes
can highlight the three-dimensional nature of
some bites);
An overall body shot showing the location
of the injury;
Close-ups that can easily be scaled 1:1;
UV photography if the injury is fading;
If the bite is on a moveable anatomical
location, then several body positions should
be adopted in order to assess the effect of
movement.
All of the photographs should be
taken with the camera at 90 (perpendicular)
to the injury. It should be emphasized to
forensic photographers that it is not possible
to have too many photographs of an injury!
It has been recommended that bitemarks are
photographed at regular 24 hour intervals on
both the deceased and living victim as their
appearance can improve. Photographs of the
bitemark will be employed in any subsequent
analysis and therefore must be of the highest
standard if the forensic significance of the
injury is to be maximized. It is possible for
a bitemark with high forensic value to be
poorly photographed and thus lost as a
valuable piece of physical evidence. Figure
4 demonstrates some common errors in
bitemark photography and Figure 5 provides

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an example of a late presenting bitemark

photographed under UV conditions. Figure
7 illustrates the impression materials that
should be used for collecting impressions of
the teeth and, if required, from the victims
skin. It should be noted that this is only
undertaken when there is a great deal of three
dimensional detail to the bite injury.
Following photography a number
of other items should be collected:
Dental impression of the victim this
is to exclude them as self-biting and for
comparison to any bite injuries that may be
discovered on a suspect.
DNA swabbing of the injury site this
should be a double swab the first moistened
with distilled water and the second dry.
Impression of the bite injury this should
only be performed if a significant degree of
three-dimensional detail is present and, in the
authors experience, rarely produces anything
of analytical value.
Skin removal recommended by certain
authorities as it permits trans-illumination
of the bitemark but again has been shown
to be flawed owing to skin contraction and
therefore few odontologists practice this.
The role of this evidence in the
ultimate analysis of the bite injury is described
below. One interesting development in the

The collection of evidence from

the bite suspect must commence only after
proper consent has been acquired. Consent
varies from jurisdiction to jurisdiction; in the
UK, for example, the individuals consent is
required before the collection of any intimate
sample (dental impressions included), under
the Police and Criminal Evidence Act (PACE),
whereas in Canada a warrant can be obtained
compelling the individual to provide such
evidence. Once authority has been obtained,
evidence collection begins, again, with
copious photography. Shots that should be
taken include:
Overall facial shot;
Close-up photograph of the teeth in normal
occlusion and biting edge to edge;
Photograph of the individual opening as
wide as possible;
Lateral view.
A thorough dental examination
should be undertaken and a dental charting
produced detailing the presence and
condition of each of the teeth, as well as
noting any recent dental treatments or dental
modifications that have been undertaken.
The next stage is to take two high
quality impressions of both the upper and
lower arches. If the individual wears a dental
prosthesis, impressions should be taken with
this being worn and also without. The author
recommends the use of poly-vinyl siloxane
(PVS) impression material (Figure 7a), to be
combined with plastic stock trays (Figure
7b). This enables the material to be poured
and cast at a later time. The use of alginate
materials is acceptable but they must usually
be poured within 12 hours of the impression
to prevent contraction. A further benefit of
PVS materials is that they can often be poured
multiple times should there be an error, for
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accidental or non-accidental. The presence

of a bitemark can often refute a parent or
guardians version of events; bitemarks are
never considered accidental, although some
injuries caused by teeth (for example a child
accidentally strikes his/her parent in the
mouth leaving tooth marks on the hand) may
be.
The American Board of Forensic
Odontology provide a range of conclusions
to describe whether or not an injury is a
bitemark. These are:
Exclusion The injury is not a bitemark.
Possible bitemark An injury showing a
pattern that may or may not be caused by
teeth, could be caused by other factors but
biting cannot be ruled out.
Probable bitemark The pattern strongly
suggests or supports origin from teeth but
could conceivably be caused by something
else.
Definite bitemark There is no reasonable
doubt that teeth created the pattern.
The first stage of any analysis is
to determine if the injury is a bitemark, and
then to provide a statement on the forensic
significance. If one or more suspects dental
casts are available, and the bitemark is suitable
for analysis, then an overlay comparison can
be conducted.
Pattern analysis in bitemark evidence

Figure 3. Visual index of the bitemark severity and significance scale. Numbers on images relate to scale
shown in Figure 2.

example an air blow, in a cast.

An example of a set of dental
casts is shown in Figure 8, which demonstrates
the importance of multiple impressions if
a suspect wears a removable prosthesis. A
sheet of softened wax should be used to
obtain an indication of how the individual
bites together, providing an occlusal record
(Figure 9). If indicated, a buccal swab should
be taken of the suspect in order to obtain a
DNA sample. In the UK, this will most likely
be collected by the police during the normal
booking procedure.
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Analysis of bitemark injuries

The preceding sections have
described the impact of a variety of factors
upon the forensic significance of bitemarks.
Only a bitemark that exhibits at least class
characteristics of the biter should be analysed.
This does not render the less significant
bitemark worthless within an investigation.
For example, if sufficient detail exists to
identify the injury as a probable bitemark, this
can be of assistance to investigators, especially
in cases of child abuse where there may be
several injuries that are ambiguous, ie may be

While metric analyses of bitemarks

are a crucial stage within the analytical
process, it is the assessment of the bite pattern
that often serves to be the most revealing.
Such analysis is usually conducted using a
transparent overlay (Figure 10). Overlays are
produced from the dental casts of suspects,
and are a representation of the biting edges
of the teeth reproduced on transparent sheets
at life size.12 The overlays are then placed over
the scaled 1:1 photographs of the bite injuries
and a comparison is undertaken. This process
is highly subjective and has been the focus of
much research, much of it determining that
such analyses are neither reliable nor accurate,
although this is very much dependent on the
quality of the bitemark and the experience
of the examiner.13 If overlay analyses are
restricted to those bitemarks displaying
unique characteristics, the process, in the
hands of an experienced odontologist, can be
highly accurate. It is therefore crucial to the
success of bitemark analysis that proper case
selection is undertaken. Therefore, it would
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Figure 4. Common photographic errors in bitemark evidence collection: (a) non-rigid scale applied
in inappropriate position on skin, no lateral element to the scale; (b) non-lateral scale that has been
pushed into the breast tissue creating visual distortion; (c) non-lateral scale that is placed too close
to the injury, possibly covering aspects of interest; (d) non-lateral scale held non-parallel to injury and
poor illumination of wound; (e) focus is centred on an area in which there is no injury; as this is a curved
surface numerous images would be required to correct for this. Inappropriate non-rigid scales; (f) a
photocopy of the ABFO scale has been glued to cardboard inaccurate.

Figure 5. Example of UV photography on a bitemark some 8 weeks after assault: (a) injury photographed
at presentation, living victim reports being bitten some two months earlier; (b) under UV conditions
unique features of the dentition can be visualized.

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be unwise to analyse an injury that was only

determined to be possible, although there
are always exceptions to these guidelines.14
Many odontologists believe that bitemark
analysis should only be used to exclude an
individual, particularly if the evidence is not of
the highest quality.
There are a number of methods
for producing bitemark overlays and, again,
these methods have been the subject of
numerous research projects.14 Two studies
are described. The first assessed the five main
methods of bitemark overlay production:
Computer-based;
Two types of radiographic;
Xerographic; and
Hand-traced.15
For many years, hand-traced
overlays were the method of choice and
these were slowly replaced by a photocopier
technique. Sweet and Bowers determined
that computer-generated overlays were by
far the most accurate in terms of both tooth
area and rotation. Given this, a number of
different modifications of the computergenerated technique were developed and
further research examined which of these was
the most effective. Results demonstrated that
both of the main techniques were reliable, and
the choice of method was down to personal
preference.15
However, while the overlay
production method has been shown to
be reliable, the application of these to the
bitemark photographs, and the assessment
of degree of match has not enjoyed as
much scientific support. Again, a range of
conclusions is available to odontologists to
describe the results of a bitemark comparison:
Excluded There are discrepancies between

Figure 6. 3D rendering of a bitemark from a

standard image.

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Figure 9. Example of a wax bite obtained from a

bitemark suspect.

owing to its complex anatomy. A bitemark

case example is shown in Figure 11.
Bitemarks and DNA

Figure 7. Impression materials used in the

collection of bitemark evidence: (a) impression
materials including two grades (light and medium
body) of polyvinyl siloxanes and one of alginate;
(b) stock impression trays such as these are
appropriate for bitemark evidence collection.

the bitemark and suspects dentition that

exclude the individual from making the mark.
Inconclusive There is insufficient forensic
detail or evidence to draw any conclusion on
the link between the suspects dentition and
the bitemark injury.
Possible biter Teeth like the suspects could
be expected to create a mark like the one
examined but so could other dentitions.
Probable biter Suspect most likely made the
bite; most people in the population would not
leave such a bite.
Reasonable medical certainty Suspect is
identified for all practical and reasonable
purposes by the bitemark any expert with
similar training and experience, evaluating
the same evidence, should come to the same
conclusion of certainty.
The second study examined
the use of these conclusion levels with a
series of 10 bitemark cases sent to experts in
odontology. The results showed that the area
under the ROC curve (a measure of sensitivity
and specificity) was 0.8 (SD 0.18). However, at
the level of reasonable medical certainty the
sensitivity was only 27.5%.13
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Figure 8. Example of stone casts produced from

a bitemark suspect: (a) cast model of suspects
maxillary arch without dental prosthesis in place;
(b) cast model of suspects maxillary arch with
partial denture in place; (c) cast model of suspects
mandibular arch.

The premise of these analyses

is that human anterior teeth are unique and
that this asserted uniqueness is replicated
on the bitten substrate in sufficient detail to
enable a match to a single individual to the
exclusion of all others.16 While in many cases
this is possible, ie bitemarks of high forensic
significance with good unique details, in the
majority it is not and therefore caution should
be taken when assessing any bite injury using
pattern analysis. It should be remembered
that skin is a poor bite registration material

As with the introduction of

molecular biology to dental identifications,
the use of DNA in bitemarks was pioneered
in an effort to eliminate the subjectivity
associated with conventional analyses.17 Much
of this work was undertaken by Sweet, who
investigated the deposition of saliva during
the biting process and its collection over
protracted periods of time from cadavers.
In order to maximize the DNA collected,
Sweet recommends that bitemarks should
be double swabbed, the first swab being
moistened with distilled water and the second
being dry. It is thought that the wet swab
rehydrates the salivary constituents, releasing
more epithelial cells from the dried deposit.18
Sweet has further used these techniques
in numerous bitemark cases, with a good
example being provided in the literature
where a conventional bitemark comparison
was undertaken followed by a DNA analysis.19
The DNA was collected from a victim who had
been in a fast running river for over 5 hours
(Figure 12).
Other methods of analysing bitemarks

A number of additional, somewhat

esoteric methods for bitemark analysis exist.
A fundamental problem in the adoption of
new technologies into bitemark analysis is
the nature of the practitioners. Most forensic
odontologists practice part-time, with the
majority of their work taking place within
private or hospital practice. Many do not have
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Figure 11. Bitemark case example: (a) photograph

of bitemark demonstrating unique features of
dentition therefore of high forensic significance
a positive bitemark; (b) the suspects maxillary
overlay (produced digitally) placed on the scaled
photograph demonstrating a positive match for
the unique features without any unexplained
discrepancies. The suspect is identified as the
definite biter.

Figure 10. Overlay production methods and

example of resultant overlay: (a) hand-drawn
technique using acetate sheets and marker pen;
(b) photocopier technique (note ABFO scale
included to check scaling); (c) digitally scanning
cast (note ABFO scale included to check scaling);
(d) example of each type of overlay.

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access to laboratories or extensive facilities

that would enable them to implement
methodologies such as DNA typing of bacteria
or SEM analysis of bite wounds.20
While the recovery of salivary DNA
has been reported as described above, the
recovery of DNA is not always assured. It has
been proposed that the presence of nucleic
acid-degrading enzymes (nucleases) within
saliva can rapidly degrade DNA, especially if
it is on a living victim, as the skins ambient
temperature accelerates the process. This is
perhaps why Sweets double swab technique
works; it collects DNA sequestered within
the oral epithelial cells as a result of the
re-hydration, rather than just relying upon
pure salivary DNA. However, accepting that
limitations exist, researchers have investigated
other markers that may be of discriminative

Figure 12. DNA collection from bitemark victims

and suspects: (a) kit required for collection from
either victim or suspect, including two swabs
(for skin only, buccal suspect swabs require only
one), gloves, card drying rack, evidence stickers,
sealable plastic bag, documentation and evidence
envelope; (b) example of a double swab being
dried prior to placement in sealed evidence bag.
Drying is a crucial stage and can take up to 30
minutes.

value within saliva deposited during a

bitemark. One such method is the recovery of
bacterial DNA.21
The human mouth contains
over 500 distinct species of bacteria, and
every individual will have a slightly different
combination, dependent on, for example, oral
hygiene status, dental status and the presence
or absence of a prosthesis. One research
group has suggested that the genotypic
identification of oral streptococci may be of
use in bitemark analyses and, while accepting
a number of limitations to the technique, have
published findings which are encouraging.
They assessed a single, experimental
bitemark against 8 possible suspects. A
total of 105 genotypes were isolated from
these 8 individuals and none was shared,
and the bitemark was correctly identified.
Interestingly, the researchers resampled the
volunteer suspects one year later and found
that their genotypes had remained stable
and the biter could still be correctly identified.
Perhaps most importantly, the remainder
of the suspects could be excluded.21 The
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Figure 13. DNA profiled from oral bacteria.

Comparison of AP-PCR products derived from four
Streptococcus colonies isolated from a self-inflicted
bitemark (B) with four from the lower incisors of
the biter (T). Reproduced with permission from
Dr J. Keiser.

Figure 14. Bitemark on non-human substrate,

perishable items. Bites such as this should be
carefully photographed, swabbed and then an
impression should be taken to allow a docking
analysis to be conducted. Depending on the item,
long-term storage in a freezer may be possible, for
example in the case of cheese.

technique is therefore a valuable addition to

the armamentarium of the forensic dentist,
although its widespread use will be limited
by access to the expertise and equipment to
undertake it (Figure 13).

Bites on perishable items, nonhuman substrates

The previous sections of this
article have concentrated on bitemarks on
human skin, as this is by far the commonest
bitten substrate that forensic dentists are
asked to assess. However, bites can occur
in many other substrates and case reports
describe such things as apples (Figure 14),22
cannabis resin,23 sandwiches,24 bank books,

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pencils,23 pacifiers, Styrofoam cups, envelopes,

and, of course, cheese.23,25,26 The forensic
value of bites in such materials is based upon
the nature of the material itself, ie a bite in
Styrofoam is likely to yield more information
than one on bread, and cheese more so than
on an apple and, in the case of perishable
items, how long ago the bite took place and
what steps were taken to preserve the object.7
A bitemark survey conducted
by the American Academy of Forensic
Sciences described Diplomates of the ABFO
undertaking only 13 cases of bites on nonhuman substrates and only one of these
was presented in Court.27 Since that time a
number of case reports have been presented
where DNA was acquired from inanimate
objects; impressively one from cheese and
an item known to confound DNA analyses28
owing to its bacterial content. So, while not a
common undertaking, it is important for both
investigative professionals and odontologists
to be aware that bitemarks in inanimate
objects can be of assistance in criminal
investigations, although the same principle of
bitemark assessment applies, ie that the bite
must hold a high level of forensic significance
before it can be considered for comparison to
a suspect for the purposes of identification.
The collection of a DNA swab from such items
should always be considered and the double
swab technique, with adequate drying and
storage, should be the method of choice.15
The analysis of bitemarks on
inanimate items varies. For example, in
bitemarks on cheese, chocolate, or apples a
docking procedure may be undertaken. In
these cases, the dental model of a suspect
is applied to a cast of the bitten object to
determine if they dock or match. Such
analyses are relatively simple, and are easily
documented for presentation in court. Bites
on flat surfaces, for example on paper, can
be analysed using an overlay technique, as
would be done for a bitemark on skin. The
conclusions that are reached are the same as
those for traditional bitemark analyses.

Conclusion
The field of bitemark science
is expanding, and the need for individuals
trained and experienced in the recognition,
collection and analysis of this type of evidence
is increasing. The often serious nature of the
crimes in which bites are found dictates that
the highest level of forensic standards should

be applied and that analyses of such injuries

should only be undertaken if unique or, in
certain circumstance, class characteristics
exist. Research into more objective methods
of bitemark analysis has produced techniques
such as salivary DNA recovery and bacterial
genotyping, although further efforts to reduce
subjectivity in standard physical techniques
are required.
Acknowledgements

The author would like to thank Dr Borgula for

supplying Figure 13.

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Hi-Di Wins Again

ForensicDentistry

I wonder why?

1994. Med Sci Law 1998; 38(1): 3441.

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An improved method to recover saliva from human skin: the
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pg48-61 Forensic dentistry 2.indd 14

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